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Maternal psychosocial predictors of pacifier use in a mother-infant interaction task: An observational study from the MPEWS pregnancy cohort

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Highlights

  • Lower emotional availability at 6 months is associated with mothers more likely using a pacifier.

  • Women with depression were no more likely to use a pacifier during the interaction.

  • Women with childhood trauma history were no more likely to use a pacifier during the interaction.

Abstract

The prevalence of pacifier use is high but when it occurs outside of the recommended sleep context, it becomes more controversial. Using 211 mother-infant dyads recorded as part of the Mercy Pregnancy and Emotional Wellbeing Study, we examined the maternal psychosocial predictors of pacifier use within an interaction task (i.e., ten minutes face-to-face followed by 30-minutes unstructured play). Predictors included maternal emotional availability measured with the Emotional Availability Scales; depression measured by the Structured Clinical Interview for the DSM-IV-TR Clinician Version; and maternal history of childhood trauma measured by the Childhood Trauma Questionnaire. An unadjusted odds ratio demonstrated that women classified as non-emotionally available to their infants were three-and-a-half-times more likely to use a pacifier. Multivariate logistic regression including all maternal psychosocial predictors demonstrated that even when adjusting for cessation of breastfeeding, maternal emotional availability remained the only significant predictor of pacifier use. This is the first time that predictors of pacifier use have been examined with a sample of clinically depressed women, as well as women with childhood trauma history. The results provide preliminary evidence that women who are not emotionally available might be more likely to rely on a pacifier during mother-infant interaction.

Introduction

Pacifiers are used by parents for their infants as an aide to assist in sleep and settling. The use of pacifiers to settle infants to sleep has been investigated in relation to its impact on breastfeeding (e.g., Barros et al., 1995; Righard & Alade, 1997; Aarts, Hörnell, Kylberg, Hofvander, & Gebre-Medhin, 1999; Marques et al., 2001), child safety, (e.g., L’Hoir et al., 1999), as well as medical (e.g., middle ear infection; Niemelä, Uhari, & Möttönen, 1995; pain relief; Elserafy, Alsaedi, Louwrens, Sadiq, & Mersal, 2009) and immunological outcomes (e.g., Mäkinen-Kiljunen, Sorva, & Juntunen-Backman, 1992). Whilst there is a substantial body of research on the use of a pacifier particularly to settle to sleep, there is more limited knowledge on pacifier use outside of the sleep context. Conversely, pacifier use remains a controversial issue (Jenik & Vain, 2009), even though as an object designed to soothe an infant, it is possible that the pacifier may enhance maternal capacity to engage during the mother-infant interaction. Despite the complexity of implications pacifier use may have on the mother-infant interaction, to our knowledge, no study has examined pacifier use in the context of the mother-infant relationship, or how maternal psychosocial factors, such as history of childhood trauma and current mental health, might predict pacifier use. Understanding maternal predictors of broader pacifier use could inform recommendations to mothers around their use. The current study examines several maternal psychosocial predictors of pacifier use within the context of a pregnancy cohort study.

Pacifiers, colloquially also known as a dummy, soother, or comforter, are designed to stimulate nonnutritive sucking (NNS) to soothe or calm an infant. Such soothing is sometimes used to facilitate the transition to sleep but may also be used to reduce infant distress. Studies suggest that pacifier use is common, with one study showing that of 670 Australian mothers, 79% had introduced the pacifier (Mauch, Scott, Magarey, & Daniels, 2012). Similarly, in another population-based Australian study, of 22, 202 mother-infant pairs, Ayton, van der Mei, Wills, Hansen, and Nelson (2015) reported pacifier use in 53.1% of the sample, with these rates reflecting that of previous studies (e.g., Binns & Scott, 2002). Pacifier use is also documented worldwide in Japan (Nelson, Yu, Williams, & International Child Care Practices Study Group Members, 2005), the United Kingdom (Clements et al., 1997), the Netherlands (Arnestad, Andersen, & Rognum, 1997), Brazil (Victora, Behague, Barros, Olinto, & Weiderpass, 1997), Sweden (Aarts et al., 1999), the Ukraine (Nelson et al., 2005), Finland (Niemelä et al., 1995), and Australia (Callaghan et al., 2005; Binns & Scott, 2002).

There are a number of studies designed to assist women to make decisions about the use of a pacifier. Whilst some empirical evidence recommends that breastfeeding mothers consider pacifier introduction only after breastfeeding is well established (Horne et al., 2014), other studies document benefits of pacifier use. For example, pacifier use is recommended for sleeping periods only, with the potential to reduce the risk of Sudden Infant Death Syndrome (Hauck, Omojokun, & Siadaty, 2005; Mitchell, Blair, & L’Hoir, 2006); though, this might only apply to infants in adverse sleep environments (e.g., sleeping position, co-sleeping, or soft mattress; Moon, Tanabe, Yang, Young, & Hauck, 2012). In addition to the role in settling an infant to sleep, the benefit of pacifier use for pain relief is acknowledged, particularly in pre-term babies (Blass & Hoffmeyer, 1991; Carbajal, Chauvet, Couderc, & Olivier-Martin, 1999; Pinelli & Symington, 2005).

Pacifiers are also used to soothe a distressed infant without the necessary aim of falling asleep. In 174 mother/infant dyads, Pansy et al. (2008) used a semi-structured questionnaire to document mothers’ reasons for pacifier use after birth, at seven weeks and at five months. A reported 31% of mothers who initially refused pacifiers had later introduced a pacifier to soothe their infant. The authors speculated that this change might be driven by a reduction in the use of more traditional methods of soothing (e.g., rocking, carrying or breastfeeding; Kramer et al., 2001). It has further been questioned whether use of these other ‘traditional’ methods, and in particular breastfeeding, might promote the early mother-infant connection (Satter, 1990). Pacifier use for the women in this study may be an important part of their ability to respond to infant distress.

The emotional availability (EA) framework can facilitate the investigation of maternal use of a pacifier within the context of the early mother-infant relationship. From the point of view of attachment theory, the ability to soothe is a core component of an EA relationship between mother and infant (Biringen & Easterbrooks, 2008; Emde, 1980). According to this theoretical model, a sensitive mother accurately interprets their infant’s signals and needs, and responds appropriately and effectively (Ainsworth, Bell, Stayton, & Richards, 1974). EA theorists (see, Emde, 1980; Emde & Easterbrooks, 1985; Biringen, 2004) propose the EA framework to assess the quality of a mother-infant interaction (Biringen, 2004). EA is the supportive maternal presence in the context of an infant’s autonomy and exploration (Mahler, Pine, & Bergman, 1975). Most importantly, the construct refers to the affective quality of the connection between the mother and her infant (Emde & Easterbrooks, 1985). A relational and inter-subjective construct, EA requires the evaluation of how each person affects the other, rather than just how the person behaves (Biringen, Derscheid, Vliegen, Closson, & Easterbrooks, 2014). It is possible that pacifier use may interfere with maternal or infant capacity to read emotional expression (see, Rychlowska et al., 2014; Niedenthal et al., 2012). Equally, however, pacifier use might reduce maternal stress that can result from infant crying. This might be of particular importance for vulnerable mothers with mental health difficulties. With prevalence estimates in Australia that suggest as many as 16% of women experience depression in the postnatal period (Buist et al., 2006), it is possible that women with maternal depression might be more likely to rely on a pacifier during mother-infant interaction.

We located two studies that examined pacifier use in the context of maternal depression. Feldens, Ardenghi, Cruz, Scalco, and Vítolo (2013) examined 375 Brazilian women and noted that those women who reported moderate-to-severe depressive symptoms at 12 months postpartum were 40% more likely to use a pacifier in the first year than other women in the sample. However, their examination of pacifier use relied on maternal self-report. Conversely, Sipsma, Kornfeind, and Kair (2017) observed that pacifier use increased the likelihood of exclusive breastfeeding by over three-fold for mothers who reported seeking treatment for depression in pregnancy but decreased the likelihood of exclusive breastfeeding by 25% for mothers who did not report seeking treatment for depression in pregnancy. They concluded that pacifier use might be beneficial for women at risk of postpartum depression. However, depression was measured by asking mothers to report if they ‘needed any of the following services’ including ‘treatment for depression’. Someone might be experiencing depressive symptoms or meet the criteria for depression diagnosis and not recognise their need for treatment (Goldman, Nielsen, Champion, Council on Scientific Affairs, & American Medical Association, 1999), or even have self-insight into their symptoms (Taylor & Brown, 1988). It is questionable whether this study even examined women at risk of depression. Taken together, this provides a basis for investigating the association between maternal depression and pacifier use.

Closely linked to depression in adulthood is childhood abuse (Norman et al., 2012). With evidence to suggest that maternal experience of child abuse might impact on parenting (DiLillo & Damashek, 2003; Smith, Cross, Winkler, Jovanovic, & Bradley, 2014), the examination of maternal use of the pacifier during the mother-infant interaction requires consideration of maternal childhood trauma as a factor. It is not known whether mothers with a history of childhood trauma are more or less likely to use a pacifier with their infant. In fact, there is only limited literature analysing the relationship between maternal childhood trauma and the early mother-infant interaction. However, evidence points to a large effect of maternal history of childhood maltreatment on the development of maternal sensitivity and non-intrusiveness at 12 months postpartum when compared to mothers without an abuse history (Fuchs, Möhler, Resch, & Kaess, 2015). These findings replicated other research in which maternal physical and sexual childhood abuse showed a medium sized association towards hostile-intrusive maternal behaviour to infants at 18 months (Lyons‐Ruth & Block, 1996). Collectively, this research suggests that women with childhood trauma history might show dyadic differences, particularly in relation to intrusiveness. An increased likelihood of maternal intrusiveness during the mother-infant interaction is consistent with the need for interpersonal control that is documented in the context of childhood trauma experience (Lawrence, Edwards, Barraclough, Church, & Hetherington, 1995). It is possible that women with childhood trauma history may be more likely to rely on pacifier use during the mother-infant interaction.

In contrast, there is a substantial body of literature examining the relationship between breastfeeding and pacifier use, although the focus is primarily on the impact of the pacifier on sustaining and establishing breastfeeding (Centuori et al., 1999). For instance, Righard and Alade (1997) reported the breastfeeding rate for non-pacifier users at four months was 91% compared to 44% in the pacifier group. The few randomized controlled trials (RCTs) conducted demonstrate a relationship between early pacifier use and breastfeeding difficulties. In an RCT involving 700 newborns, Howard et al. (2003) noted that exclusive breastfeeding was 1.5 times less likely for mothers who introduced the pacifier in the first four weeks postpartum. This was replicated in an Australian longitudinal study that reported infants who had the pacifier introduced before ten weeks were 1.47 times more likely to discontinue full breastfeeding by six months (Scott, Binns, Oddy, & Graham, 2006). Consequently, breastfeeding must be included as a covariate in any investigation of the psychosocial drivers of this maternal behaviour.

Ultimately, to understand the maternal behaviour of pacifier use, it must be observed within the context of the mother-infant relationship in which it occurs. Infant distress and crying is a common source of parenting stress (Beebe, Casey, & Pinto-Martin, 1993), particularly in the first year as the mother is learning how to identify and respond to the infant’s cues (Ainsworth, 1979). If a mother reduces infant distress using the pacifier, the infant will provide positive feedback to the mother, which may enhance maternal self-efficacy and create a reciprocal emotional exchange between the mother and her infant (Biringen & Easterbrooks, 2012). For those mothers with depression or childhood trauma history, it is possible that use of the pacifier during mother-infant interaction may be an effective tool to reduce stress and increase enjoyment – both are core components of an emotionally available interaction.

In this study, we investigate the maternal psychosocial factors associated with pacifier use by using data from a longitudinal pregnancy cohort study, the Mercy Pregnancy and Emotional Wellbeing Study (MPEWS). Data were collected at four time points across pregnancy and the postpartum regarding maternal psychosocial predictors of pacifier use: depression, EA, and history of childhood abuse, with the covariate of breastfeeding cessation. The first aim of this study is to analyse the association between observed pacifier use during a mother-infant interaction at six months postpartum, and different maternal factors including, maternal EA, depression and history of childhood abuse. The second aim is to investigate the relationship between each of these maternal psychosocial factors and pacifier use with the data collected from early pregnancy to six months postpartum. We hypothesized that:

  • 1

    women categorised as non-emotionally available to their infants would be more likely to use a pacifier than women who were emotionally available to their infants;

  • 2

    women diagnosed with depression were more likely to use a pacifier then women without depression diagnosis; and,

  • 3

    women with a history of childhood trauma were more likely to use a pacifier than women without a history of childhood trauma.

Finally, we sought to determine which of these hypothesized predictors of pacifier use would remain unique additive predictors when included together in a multivariate model.

Section snippets

Material and methods

Data were drawn from the Mercy Pregnancy and Emotional Wellbeing Study, a pregnancy cohort study based in Melbourne, Australia (Galbally et al., 2017). Recruitment of women was at less than 20 weeks pregnancy and initially occurred through antenatal bookings. The Mercy Health Human Research Ethics Committee approved the study with participants providing their written informed consent prior to participation.

Results

At six months postpartum, 57.8% (n = 122) of mothers self-reported that they had used a pacifier, though for what purpose (e.g., settling to sleep, pain relief, during an interaction) is not known. The mean age for introducing the pacifier was 4.39 weeks (SD = 4.71), ranging between 0 and 27 weeks. Breastfeeding was initiated for 96.6% of mother/infants, and 19.4% (n = 41) of women had ceased breastfeeding at six months postpartum. Further details regarding breastfeeding in this cohort is at

Discussion

To our knowledge, this is the first time that researchers have investigated the maternal psychosocial predictors of pacifier use for non-sleep settling purposes. We found that women categorised as non-emotionally available to their infant were three-and-a-half times more likely to use a pacifier than women categorised as EA. This effect remained in our final multivariate model, so that even when adjusting for the confounding effects of breastfeeding cessation, maternal EA remained a significant

Credit statement

Kelli K MacMillan: Conceptualization of this study, Assessment of mother-infant interactions and identification of pacifier use, Formal analysis, Writing original draft, Writing - review and editing; Andrew J Lewis: Conceptualization of MPEWS and this study, Methodology of MPEWS, Supervision of assessment of mother-infant interactions and identification of pacifier use, Formal analysis, Investigation, Resources, Writing - review and editing, Supervision, Funding acquisition; Stuart J Watson:

Funding

This study is supported through the 2012 National Priority Funding Round of Beyond Blue in a three-year research grant (ID 519240), and a 2015 National Health and Medical Research Council (NHMRC) project grant for 5 years (APP1106823). Financial support has also been obtained from the Academic Research and Development Grants, Mercy Health and Centre for Mental Health and Well-Being, and Deakin University.

Declaration of Competing Interest

The authors declare that they have no competing interests.

Acknowledgements

The authors would like to thank those who have supported the development of the Mercy Pregnancy and Emotional Wellbeing Study including Marinus van IJzendoorn and Michael Permezel. In addition, Marian Bakermans-Kranenburg, Peter Fonagy and Robert Emde in the design of the postpartum assessment within the study. The authors also thank staff, students and volunteers on the MPEWS study as well as study coordinators: Nicole Brooks and Tina Vaiano. In addition, students and staff who assisted with

References (81)

  • L. Tonmyr et al.

    Measurement of emotional/psychological child maltreatment: A review

    Child Abuse & Neglect

    (2011)
  • C. Aarts et al.

    Breastfeeding patterns in relation to thumb sucking and pacifier use

    Pediatrics

    (1999)
  • M.S. Ainsworth

    Infant–mother attachment

    The American Psychologist

    (1979)
  • M.D.S. Ainsworth et al.

    The introduction of the child into a social world

    (1974)
  • M. Ainsworth et al.

    The strange-situation procedure

    Patterns of attachment

    (1978)
  • M. Arnestad et al.

    Is the use of dummy or carry-cot of importance for sudden infant death?

    European Journal of Pediatrics

    (1997)
  • J. Ayton et al.

    Cumulative risks and cessation of exclusive breastfeeding: Australian cross-sectional survey

    Archives of Disease in Childhood

    (2015)
  • F.C. Barros et al.

    Use of pacifiers is associated with decreased breast-feeding duration

    Pediatrics

    (1995)
  • S.A. Beebe et al.

    Association of reported infant crying and maternal parenting stress

    Clinical Pediatrics

    (1993)
  • D.P. Bernstein et al.

    Childhood trauma questionnaire (CTQ)

    (1999)
  • C.W. Binns et al.

    Using pacifiers: What are breastfeeding mothers doing?

    Breastfeeding Review : Professional Publication of the Nursing Mothers’ Association of Australia

    (2002)
  • Z. Biringen

    Raising a secure child: Creating emotional availability between you and your child

    (2004)
  • Z. Biringen et al.

    Child-care and relationships: Understanding relationships and relationship interventions

    Journal of Early Childhood and Infant Psychology

    (2008)
  • Z. Biringen et al.

    Emotional availability: Concept, research, and window on developmental psychopathology

    Development and Psychopathology

    (2012)
  • Z. Biringen et al.

    Emotional availability scales

    (1998)
  • Z. Biringen et al.

    Emotional availability scales (4th ed.)

    (2008)
  • E.M. Blass et al.

    Sucrose as an analgesic for newborn infants

    Pediatrics

    (1991)
  • M.H. Bornstein et al.

    Short-term reliability and continuity of emotional availability in mother–child dyads across contexts of observation

    Infancy

    (2006)
  • M.H. Bornstein et al.

    Emotional availability in mother-child dyads: Short-term stability and continuity from variable-centered and person-centered perspectives

    Merrill-Palmer Quarterly

    (2006)
  • G.D.S. Buccini et al.

    Pacifier use and interruption of exclusive breastfeeding: Systematic review and meta‐analysis

    Maternal & Child Nutrition

    (2017)
  • S. Butler et al.

    Factors associated with not breastfeeding exclusively among mothers of a cohort of Pacific infants in New Zealand

    (2004)
  • A. Callaghan et al.

    Association between pacifier use and breast‐feeding, sudden infant death syndrome, infection and dental malocclusion

    International Journal of Evidence-based Healthcare

    (2005)
  • R. Carbajal et al.

    Randomised trial of analgesic effects of sucrose, glucose, and pacifiers in term neonates

    Bmj

    (1999)
  • S. Centuori et al.

    Nipple care, sore nipples, and breastfeeding: A randomized trial

    Journal of Human Lactation

    (1999)
  • M.S. Clements et al.

    Influences on breastfeeding in southeast England

    Acta Paediatrica

    (1997)
  • D. DiLillo et al.

    Parenting characteristics of women reporting a history of childhood sexual abuse

    Child Maltreatment

    (2003)
  • S.I. Elmhirst

    Transitional objects in transition

    The International Journal of Psycho-analysis

    (1980)
  • F.A. Elserafy et al.

    Oral sucrose and A pacifier for pain relief during simple procedures in preterm infants: A randomized controlled trial

    Annals of Saudi Medicine

    (2009)
  • R.N. Emde

    Emotional availability: A reciprocal reward system for infants and parents with implications for prevention of psychosocial disorders

    Parent-infant relationships

    (1980)
  • R.N. Emde et al.

    Assessing emotional availability in early development

  • View full text